Inspection on 03/11/06 for Freeman House

This inspection was carried out on 3rd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Freeman House 28/10/08

Freeman House 20/02/06

Freeman House 17/08/05

Freeman House 10/02/05

Freeman House 10/08/04

Freeman House 03/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Freeman House Radburn Way Letchworth Hertfordshire SG6 2LH Lead Inspector Mrs Alison Butler Unannounced Inspection 3rd November 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Freeman House Address Radburn Way Letchworth Hertfordshire SG6 2LH Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01462 488000 01462 488064 www.quantumcare.co.uk Quantum Care Limited Nina Parry Care Home 48 Category(ies) of Dementia - over 65 years of age (48), Old age, registration, with number not falling within any other category (48), of places Physical disability over 65 years of age (48) Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th February 2006 Brief Description of the Service: Built circa 1965, Freeman House is a large three storey building located in a residential neighbourhood of Letchworth close to local shops and amenities. Fees for the service range from £400- £505 per week (this was correct as of 03/11/06) The home is furnished to a good standard and provides a comfortable and reasonably homely environment that belies the rather stark external appearance. Accommodation is provided on three floors served by a lift. There are communal lounges and a kitchenette/dining room on each floor as well as a functions room on the ground floor. All bedrooms are singles, although provision can be made for couples who wish to share. There are three shower facilities but no en-suite facilities in bedrooms. Additional rooms comprise a hairdressing room, staff room and various offices. Accommodation can be provided for visitors if required. There is a car park to the front of the building and a pleasant garden to the rear. The home provides a growing range of weekly activities, with visits from outside entertainers, days out and regular social events. Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted with the manager, staff and residents. There were 48 residents including 1 in hospital at the home. The focus of this inspection was to cover all the key standards and follow up on the requirement made at the last inspection. The majority of the inspection was spent talking with residents and observing staff, an examination of various care records was also carried out. The inspector also attended the home’s forum to seek the views of relatives and visitors about the conduct and service that is provided at Freeman House. What the service does well: What has improved since the last inspection? The company have employed a pharmacist inspector and although there were some errors noted during his visit, overall the system works well and is well managed. The ground floor activities lounge has been redecorated and provides a relaxing area for residents to enjoy if they so wish. They may also use the lounge for sitting with their friends and relatives who visit them. Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standard 6 is not applicable to Freeman House Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All admissions are made on the basis of a full assessment. EVIDENCE: From the files inspected, pre admission assessments were completed and held within their personal files. The admission assessment forms is used to develop an individual care plan. Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans cover the full range of health; personal and social care needs for the residents. A well-managed and safe medication is in place. EVIDENCE: Two care plans were examined, they contained comprehensive information. Quantum Care are in the process of introducing a new care plan format and the information is being transferred. Staff should remember when changes have occurred to the care needs that these should be signed and dated it would also demonstrate that reviewing is taking place. Where risk assessments are in place they should be individualised for the resident and not just have a generic and only adds the named individual, although not all information is relevant to the person. The care plans sampled had been updated. Residents were treated with respect and staff were seen to knock and wait before entering residents rooms. Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 10 The company have employed a pharmacy inspector who carries out medication audits. One had taken place the day before this inspection visit and a copy of the report was available. This has been used to form a judgement. A number of minor issues were raised which included staff failing to sign additional information, an attempt to rub out or use Tippex on the recording sheet, and where given as required medication states “one or two tablets to be given” staff are trying to include it on the front of the recording sheet, whereas it should be recorded on the back of the sheet. The temperature of the new medication storage arrangements should be recorded to ensure that medication is stored correctly in line with manufacturers instructions. It was also noted that where residents were routinely refusing medication this should be brought to the GP’s attention. Other than this the medication arrangements were in good order. Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to follow a lifestyle they choose. Visitors are welcomed into the home at any reasonable time. Varied and nutritious meals and snacks are provided. EVIDENCE: Residents spoken to were very happy with their lives at Freeman House and stated they are able to choose to join in the activities on offer. They have regular entertainers that visit the home, which they very much enjoy. The residents said that their friends and family are able to visit the home at any time and are very much welcomed and hospitality is provided. Staff were observed offering appropriate support to residents and encouraging independence where possible. Most residents were complimentary about the food although some said it could be better. The menu provides a varied and balanced diet. Residents were able to choose where to eat their meals and staff provided support where necessary although a new member of staff should be reminded when assisting residents they should be seated so as not to appear to hurry them. The lunch of the day was cottage pie/vegetarian pie and vegetables. Pineapple sponge & custard Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 12 fruit and or ice cream. The inspector sampled the meal, which was tasty and well presented. Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust procedures are in place to ensure the protection of the residents. A comprehensive complaints policy is in place. EVIDENCE: Residents who were spoken to are clear that they can speak to any member of staff if they had any concerns about their lives at Freeman House. There is a complaints procedure in place and examination of the file showed that a complaint received had detailed the action taken and feedback had been given to the complainant and they were happy with the outcome. Staff are provided with training in adult protection and the home use the Hertfordshire Adult at Risk Procedure which staff were familiar with the process should an allegation of abuse occur. Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean and well maintained and regular maintenance checks are carried out on service and equipment. EVIDENCE: Ramps have been provided outside the patio doors, this provides easier access to those in wheelchairs. The lighting in the corridors is to be upgraded which would brighten those areas for those whose sight is not as good. The kitchens on the middle and top floors are to be replaced and appropriate risk assessments will be put in place and forwarded to the Commission For Social Care Inspection prior to the work commencing. Additional work is to take place at the front of the building to provide easier access into the home for wheelchair users. Adequate laundry facilities are in place to meet the residents’ needs. Residents all looked well dressed and stated they were happy with the laundry service. Policies and procedures are in place to control the spread of infection. Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures are in place. Adequate numbers and deployment of staff are in place to meet the residents’ needs. EVIDENCE: On the day of the inspection the manager, nine care staff, two care team managers, three housekeepers, the administrator, a cook and a kitchen assistant were on duty. The rota showed that this is the typical staffing level. This was adequate to meet the personal care needs of the residents at the time of this inspection. Staff are provided with a full induction programme on commencing employment. There is an on-going training plan in place and this ensures that staff maintain their skills and keep up to date with practise. The home has over 50 of care staff with an NVQ level 2 or above. Residents spoken to were very happy with the staff and stated, “they are lovely girls and can’t do enough for us”. Staff files examined contained all the relevant paperwork prior to commencing employment. Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good systems are in place for the monitoring of care and to ensure the home is run in the best interests of the residents. The health safety and welfare of residents and staff is promoted by safe working practises, although some work is required on risk assessments. EVIDENCE: The home held a forum in September to which relatives of residents were invited, the inspector also attended. This meeting, although poorly attended by relatives, it provided those that did with information from the recent quality assurance questionnaire and where improvements could be made. Those relatives that the inspector spoke to during the evening were all positive about the care that is provided at Freeman House and felt that if they had any concerns they would be dealt with appropriately. They stated that their Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 17 relatives were also very happy with the care and could ask for nothing more. “The staff are wonderful and help us with everything” was a comment received from a resident. The health safety and welfare of residents, staff and all who visit the home are safeguarded as far as is possible via a system of checks. Although risk assessments are in place, they should be individualised as a generic copy is in use with the persons name added to it. Whilst this is good at providing a check list of things to put within the risk assessment, not all of the information is relevant to an individual or to the home. There are good financial procedures in place although these were not inspected on this occasion an audit of the accounts takes place regularly. Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 19 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP38 Good Practice Recommendations The manger should ensure that all risk assessments are written for a individual and meet their needs. Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Hertfordshire Area Office CPC1 Capital Park Fulbourn Cambridgeshire CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Freeman House DS0000019390.V318530.R01.S.doc Version 5.2 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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